Introduction

Human immunodeficiency virus (HIV) infection in pregnancy creates complex and challenging moral dilemmas, both for pregnant women and for those involved in their care. A recent breakthrough in research has shown that mother-to-child transmission (vertical transmission) can be reduced with the use of anti-viral drugs (Connor et al., 1994), with obstetric interventions – Caesarean section in particular (European Mode of Delivery Collaboration, 1999) – and with avoidance of breast-feeding. These findings have made pregnant women the focus for preventative and therapeutic strategies, and for public health policies. They have provided the impetus for further research into cheaper and simpler ways to reduce vertical transmission in resource-poor countries. They have also generated ethical challenges and dilemmas at both the individual and the global level.

Setting the scene

HIV-related disease, AIDS, now kills more people worldwide than any other disease. In 1998, two and a half million people died from AIDS. A report in 1999 from the United Nations AIDS program (UNAIDS, 1999) cited the prevalence in 1998 as being 33.4 million, a rise of 10 per cent (nearly six million new cases), from the year before. This shows a disturbing lack of progress in prevention nearly 20 years into the epidemic. People living in sub-Saharan Africa account for two-thirds of those infected with the virus. The majority of these infections are acquired from heterosexual or vertical transmission.

Females in sub-Saharan Africa are particularly vulnerable to HIV infection. Rates in girls are three to four times that of boys (Malloch Brown, 2000).